Message to all Nurse Endoscopists

Monday, 19 July 2010 09:24

Message to all Nurse Endoscopists

The range of procedures being undertaken by nurse endoscopists is extending to include more therapeutic interventions particularly at bowel screening colonoscopy. It is timely therefore to review the issues relating to the administration of opiates by nurse endoscopists. A BSGE working party chaired by Dr Miles Allison Consultant Gastroenterologist convened in June to address these issues. The intention was also to review current practice involving other drugs including polyp lifting solutions used for endoscopic mucosal resection (EMR). In addition to representative nurse endoscopists from across the UK the meeting was also attended by Jane Brown, Director of Policy and Implementation from the National Prescribing Centre, David Cressey Consultant Anaesthetist representing the Royal College of Anaesthetists, Rick Forbes-Young representing the Royal College of Nursing and Pauline Hutson Representing the Endoscopy Associates Group.

Summary of Working Party Meeting

At the current time the administration of an opiate prior to an endoscopy procedure has to be prescribed by a doctor in advance of procedures.

Proposals to expand the range of controlled drugs and the settings in which these can be administered by nurses working under Patient Group Directions (PGDs) have not been approved.

It is understood that the changes in legislation to support independent nurse prescribers to prescribe controlled drugs in a wider range of settings is being proposed at parliament. Until such time independent nurse prescribers can only prescribe a limited number of opiates for specific indications as listed in the BNF under ‘nurse prescribers’ formulary.

In view of the high probability of these changes it might be in the best interests of Trusts looking at employing future nurse endoscopists to incorporate into job plans access to an independent nurse prescribers six month university based course. Job descriptions should state that administration of intravenous sedation and intracolonic injections will be expected as part of their role.

In 2008 the Medicines and Healthcare products Regulatory Agency (MHRA) confirmed that despite being a Schedule 3 drug midazolam could be administered under a PGD.

A Patient Specific Direction (PSD) can be used as an alternative to a prescription but this has to be written by a doctor once the patient has been assessed. A dose range needs to be set and a prescription for opiates is valid for 28 days only.

PGDs should be available for Midazolam, Flumazenil, Hyoscine (Buscopan), oxygen, local anaesthetic throat spray, adrenaline, entonox (where used) and bowel preparation products. PGDs identify the nurses competent to administer these agents and also state maximum and minimum dosing ranges.

Nurse endoscopists working in Wales, Scotland and Northern Ireland need to ensure that Chief Nursing Officers in addition to Chief Pharmacists are aware of all PGDs in use.

Currently some nurse endoscopists are practising legally by using PGDs for midazolam and entonox for nurse-led colonoscopy thus avoiding the use of opiates.

The following information has been gained since the meeting and refers to the use of sub-mucosal injections of dyes for EMR:

Methylthioninium chloride (methylene blue) injection 1% is licensed in the UK for administration by IV injection in the treatment of methaemoglobinaemia. Therefore if this product is used as a dye or for endoscopic mucosal resection it is off-licence. In these circumstances a local Trust policy would need to be in place in collaboration with the Trust Medicines Safety Committee. If approved it may be permitted under a PGD and provided such use is supported by best clinical practice and appropriateness.

Indigo carmine 0.8% injection is sourced in the USA. This product is unlicensed in the UK and cannot be included under a PGD. It is a matter for local interpretation as to whether indigo carmine dye spraying could be incorporated within a patient specific direction as an unlicensed medicinal product or just used under a local protocol in the best interest of the patient again supported by best clinical practice and appropriateness. To our knowledge there are no reports of toxicity from such dye spraying.

SPOT contains very fine black carbon for submucosal injection as a marker in the GI tract. This product is marketed as a tattooing agent and has a CE mark indicating registration as a medical device rather than a pharmaceutical product. Information received from the manufacturer of SPOT confirms that this product was approved as a device and is not a licensed medicine. Therefore inclusion in a PGD is not permitted. However this link in the National Electronic Library for Medicine NELM PGD provides access to a document: To PGD or not to PGD (updated May 2010). The document makes it clear that only licensed medicines can be included in a PGD and at the bottom of page one is the following:

PGD legislation applies only to licensed medicines. Consider developing a local protocol or treatment guidelines for dressings and medical devices.

For those nurse endoscopists mixing sub-mucosal injections; legal requirements do not permit the mixing of medicines under a PGD unless a product is being dissolved or diluted as in the case of adrenaline and saline. If mixing is clinically appropriate and essential to meet the needs of the patient, nurse independent prescribers can mix medicines such as gelofusin and adrenaline for EMR.

This information provides a legal framework for nurse endoscopists. It is not intended to compromise practice or to stifle development. If followed it will protect nurses, managers and Trusts from potential litigation and most importantly it will ensure that patients are treated safely and carefully within the boundaries dictated by the law.